Provider Demographics
NPI:1205189578
Name:BANUELOS, JESSICA MIRELLA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MIRELLA
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21520 PIONEER BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:HAWAIIAN GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90716-2603
Mailing Address - Country:US
Mailing Address - Phone:562-246-5700
Mailing Address - Fax:
Practice Address - Street 1:21520 PIONEER BLVD STE 101
Practice Address - Street 2:
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-2603
Practice Address - Country:US
Practice Address - Phone:562-246-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner